Impact of coaching on physician wellness: A systematic review

Physician wellness is critical for patient safety and quality of care. Coaching has been successfully and widely applied across many industries to enhance well-being but has only recently been considered for physicians. This review aimed to summarize the existing evidence on the effect of coaching by trained coaches on physician well-being, distress and burnout. MEDLINE, Embase, ERIC, PsycINFO and Web of Science were searched without language restrictions to December 21, 2022. Studies of any design were included if they involved physicians of any specialty undergoing coaching by trained coaches and assessed at least one measure along the wellness continuum. Pairs of independent reviewers determined reference eligibility. Risk of bias was assessed using the Cochrane Risk of Bias Tools for Randomized Controlled Trials (RCTs) and for Non-randomized Studies of Interventions (ROBINS-I). Meta-analysis was not possible due to heterogeneity in study design and outcome measures as well as inconsistent reporting. The search retrieved 2531 references, of which 14 were included (5 RCTs, 2 non-randomized controlled studies, 4 before-and-after studies, 2 mixed-methods studies, 1 qualitative study). There were 1099 participants across all included studies. Risk of bias was moderate or serious for non-RCTs, while the 5 RCTs were of lower risk. All quantitative studies reported effectiveness of coaching for at least one outcome assessed. The included qualitative study reported a perceived positive impact of coaching by participants. Evidence from available RCTs suggests coaching for physicians can improve well-being and reduce distress/burnout. Non-randomized interventional studies have similar findings but face many limitations. Consistent reporting and standardized outcome measures are needed.


Introduction
Physician burnout represents a profound and longstanding epidemic in healthcare, with rates reported to be 1.5 times higher than the general US working population (37.9% vs. 27.8%) [1]. The prevalence of physician burnout has only been exacerbated by the COVID-19 pandemic. According to a national study conducted in 2021 in Canada, 53% of physicians and medical learners experienced symptoms of burnout, nearly double what was reported in a 2017 study (30%) [2]. The rise in physician burnout has serious consequences for both patient safety and quality of care. According to a recent systematic review and meta-analysis, physicians with burnout are twice as likely to be involved in patient safety incidents, to exhibit low professionalism and to receive low satisfaction ratings from patients [3]. Burnout is also costly to the healthcare system, with the cost to replace one physician estimated at $500 000, taking into account hiring and training costs as well as productivity losses [4].
Although many different interventions have been implemented to address physician burnout, several systematic reviews have found a wide range in effectiveness, from modest improvement in, to worsening of, burnout [5][6][7][8][9][10][11][12]. Existing interventions have largely focused on a specific stressor (e.g., modifications to electronic health record documentation to reduce associated burnout [6,7]) and are short in duration (e.g., self-care workshops, stress management skills training [9]), or unsustainable given the resource limitations of the healthcare system (e.g., reducing physician workload [9]). Interventions involving single or short-term training sessions do not show consistent evidence of effectiveness, and in several instances, have even worsened resilience upon completion [5]. Other interventions have limited capacity to generalize to all aspects of physicians' lives. For example, wellness interventions for neurosurgical faculty and residents involved free gym memberships, group gym visits, and teambased exercise sessions [8]. Evidence also suggests that interventions perceived as adding "burden" to physicians' lives (i.e., requiring a substantial time commitment outside of working hours) are unlikely to be effective [13]. These limitations highlight the need for interventions that are tailored to the complex and unique lived experiences of individual physicians, rather than imposing a top-down, one-size-fits-all approach. The most effective interventions are those designed to meet the needs of the individuals they serve [14,15]. Furthermore, evidence suggests that physicians are typically reluctant or ashamed to access mental health services or perceive that their problems are "not severe enough" [16]. Thus, initiatives framed as proactive professional development (rather than reactive) may ultimately be more accessible and effective in preventing distress and burnout, rather than offering resources too late in the game.
Coaching has been found to improve well-being and reduce burnout across many industries (e.g., finance, nuclear power, education), and more recently, healthcare [17][18][19]. The International Coaching Federation (ICF) defines coaching as "a thought-provoking and creative process that inspires [participants] to maximize their personal and professional potential." [20] Delivered by trained coaches, coaching is a proactive and action-oriented intervention intended to empower individuals to with self-discovery, strength-building and self-efficacy [20,21]. Through powerful questions and other techniques such as embodiment, active listening, curiosity, or emotional literacy, trained coaches help individuals to act according to their core values, regain control over their lives and achieve fulfillment [20,21]. Although coaching is emerging as a promising intervention for physician wellness, a comprehensive summary and appraisal of the available evidence has yet to be completed. This is necessary to guide healthcare organizations considering implementation of coaching to support physician wellness.

Objectives
We aimed to conduct a systematic review of the existing evidence on the effect of coaching by trained coaches on physician wellness.

Protocol
This systematic review was planned and conducted according to A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) standards [22] and reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [23]. The review protocol was developed a priori and published on Open Science Framework [24].

Eligibility criteria
Studies of any interventional design were included if they involved licensed physicians or postgraduate trainees of any specialty undergoing coaching by trained coaches, delivered individually or to groups. Studies had to assess at least one outcome related to wellness (e.g., quality of life, resilience, psychological well-being), distress, and burnout [25] to be included. To be included, the coaching intervention had to meet the internationally recognized definition and core competencies described by the ICF (Table 1) [20,21]. The ICF defines coaching as "a though-provoking and creative process that inspires [participants] to maximize their personal and professional potential" [20]. This was important to distinguish coaching from other interventions with which it is often confused (e.g., feedback, teaching, mentoring, peer support) [26], and was verified with specific screening questions during the reference selection process. We specifically excluded coaching interventions that did not meet the ICF standard definition or that were implemented as part of a multifaceted intervention. Studies involving medical students were also excluded. Conference abstracts, letters, editorials, and commentaries were not eligible for inclusion.

Search strategy and information sources
The search strategy was developed by an experienced information specialist (VL) in close collaboration with the research team (S1 Appendix) and reviewed by a second information specialist as per Peer Review of Electronic Search Strategies (PRESS) guidelines [27]. The databases MEDLINE, Embase, ERIC, and PsycINFO via Ovid and Web of Science were searched without date or language restrictions; however, only studies published in English or French were included in the final review. We planned to include an appendix of potentially relevant studies published in other languages; however, none were identified. The reference lists of included studies were also searched for potentially relevant studies that may not have been identified in the initial search. The final list of included studies was reviewed by coaching experts (SB, MDL, CA, AS) to confirm its relevance and completeness.

Study selection
Identified studies were uploaded to Covidence, a web-based systematic review software (Melbourne, Australia). Duplicates were detected and removed automatically by Covidence. A screening tool was developed by the research team, piloted, and iteratively refined until acceptable inter-rater reliability was established (minimum Cohen's kappa = 0.7). The tool was designed to facilitate a judgement of "include" or "exclude" based on the pre-specified inclusion criteria described above. Pairs of independent reviewers (CD, PMD, CE, MK) first assessed titles and abstracts for eligibility, followed by the full texts of articles of included studies and those deemed "unclear". Screening for inclusion at each level was always conducted in duplicate, with disagreements resolved by consensus or involvement of a third reviewer as needed (SB).

Data extraction
A data extraction form was developed and piloted, then used by the reviewers in duplicate to extract relevant information with Covidence. Extracted data included publication details (e.g., first author name, year of publication, country of data collection), study characteristics (e.g., study design, sample size, inclusion criteria), physician demographics, healthcare setting (e.g., community or academic hospital, specialty), intervention and comparator details, and the effect of intervention on reported outcomes of interest.

Risk of bias
Pairs of independent reviewers (CD, PMD, CE, MK) assessed included studies for risk of bias using the Cochrane Risk of Bias Tool 2 (RoB2) [28], and for Non-randomized Studies of Interventions (ROBINS-I) [29], as appropriate. The RoB2 tool assesses the potential for bias in terms of trial design, conduct, and reporting. Within each domain, there is a series of questions which facilitate a judgement about the risk of bias. The judgement can be "low", "high", or can express "some concerns." [28], The ROBINS-I tool includes seven domains of bias: bias due to confounding, bias in selection of participants into the study, bias in classification interventions, bias due to deviations from intended interventions, bias due to missing data, bias in measurement of outcomes, and bias in selection of the reported result [29]. Within and across each domain, a judgement is made based on specified criteria as to whether there is a "low", "moderate", "serious", or "critical" risk of bias [29].

Data synthesis
A narrative synthesis of results was conducted. We planned to conduct a meta-analysis if appropriate; however, this was not possible based on the heterogeneity in study design and outcome measures as well as inconsistent reporting.

Study selection
The literature search yielded 2531 studies. After removal of duplicates, 1756 studies were assessed for eligibility (Fig 1). Subsequently, 14 studies met the inclusion criteria and were included in this systematic review.

Study and participant characteristics
Details on included study and participant characteristics are provided in Table 2. Of the 14 included studies, 5 (36%) were RCTs, 2 were non-randomized controlled studies, 4 (29%) were before-and after-studies, 2 (14%) were mixed-methods studies, and 1 (7%) was a qualitative study. were between 41 and 50. Across the 11 studies reporting participant sex, nearly two thirds of participants were male (n = 491 [57%]).

Risk of bias
All five of the RCTs were found to be at low risk of bias across almost all domains ( Table 3). The measurement of outcome domain and the missing outcome domain were found to be at some risk of bias for the Dyrbye et al. [19] and McGonagle et al. [35] RCTs, respectively. The Palamara et al. study [40] was found to have some concerns of bias for the deviations from intended interventions domain and the missing outcome domain. The included non-randomized interventional studies and quantitative portions of the mixed-methods studies were mostly at moderate or serious risk of bias across all domains ( Table 4). The included qualitative study was not assessed for risk of bias.

Definition of coaching and qualifications of coaches
Each of the included studies fell within the ICF definition of coaching, focusing on participant-centered goals, a collaborative coach-participant relationship, strengths-development, and maximizing participants' potential or performance (Table 2). Ten studies specifically indicated that the coaches involved were accredited by a coaching organization or had professional coaching certifications. The other 4 studies indicated that coaches were trained but provided limited certification details. Details about coaches' certification for individual studies are included in Table 1.

Coaching intervention and control description
The median number of coaching sessions involved was 5.5 (IQR = 2.75) ( Table 5). Two studies did not report the number of sessions and were excluded from this calculation. Coaching sessions ranged in duration from 30 minutes to a full day. Six studies included a control group, where participants received no intervention at all or were offered coaching at the end of the study (Table 5). One study included a control group that received wellness resources via email during the study period. The other 7 studies did not include a control group (Table 5). Coaching was delivered at the group level in four studies [30,32,33,42], and at the individual level by the remaining 10 studies.

Effectiveness of coaching for improving well-being, distress and burnout
Of the 13 included studies with a quantitative component, 7 reported a decrease in emotional exhaustion (n participants = 612 [58%]) and 5 reported a decrease in overall burnout (n participants = 505 [48%]) ( Table 5). Four of the 5 studies that found a decrease in burnout were RCTs (        In the sole included qualitative study by de Lasson et al., [30] participants reported gaining "a new awareness of their patterns of thinking, feelings and reactions" and being "more at ease with themselves". Participants also reported finding new ways to take control of their professional lives (Table 5).

Summary of main findings
This systematic review identified 14 studies assessing the effect of coaching on physician wellness and burnout. Five of these studies were RCTs at relatively low risk of bias, while the included non-randomized interventional studies were mostly at moderate or serious risk of bias. Across all studies, coaching was observed to improve several outcomes related to wellness, including work/life balance, quality of life, resilience, job satisfaction, work engagement, empowerment at work, and psychological capital. Coaching was also generally observed to decrease emotional exhaustion, distress, and burnout.
The definition of coaching used in included studies was relatively homogeneous, as could be expected based on our inclusion criteria which rigorously adhered to the International Coaching Federation definition of coaching [20]. Although studies viewed coaching similarly, their implementation of coaching varied. For example, some studies involved only 3 to 4 sessions while others involved 6 or more. The duration of the sessions also differed between studies as well as the time period over which coaching was offered and whether coaching was delivered at the group or individual level. Despite this variation, coaching still appeared to positively impact participant wellness regardless of its mode of delivery. It may be worthwhile to explore the minimally effective "dose" of coaching in future research to maximize benefits for physician wellness while working within resource constraints and scheduling challenges. In addition, the optimal level of coach certification for maximizing physician wellness should be explored as it also varied between the studies included here. Currently, coaching is an unregulated profession, albeit there are national and international certification bodies. Minimum standards of coach competency and conduct may be in participants' best interest moving forward if there is a relationship between coach certification and participant outcomes.
In order to effectively make comparisons, standardized reporting and outcome measures are also needed. The included studies assessed a wide range of outcome measures and designs. Baseline and post-intervention proportions of the outcome measures were also not regularly reported. The heterogeneity in outcome measures among the included studies may reflect the lack of consensus in the broader literature regarding the best way to conceptualize and assess physician wellness [43]. Given the multifaceted nature of physician wellness, there is a need for "a shared, holistic definition. . . that explicitly includes integrated well-being constructs (e.g., purpose, thriving, vigor, work-life balance) along with mental, social and physical constructs." [43] A comprehensive and shared definition will improve the quality of research on physician wellness, including studies of intervention effectiveness, and increase comparability of findings.
Another consideration for reporting is to disaggregate results by relevant participant characteristics, such as sex, gender, and ethnicity. One of the included studies observed differential effectiveness of coaching by sex and ethnicity of participants, while other studies did not report results across these variables. Recent studies document that the prevalence, presentation, and factors contributing to burnout can vary by race/ethnicity, gender, and sexual orientation [44][45][46][47][48]. Consequently, these and other equity-related characteristics may be important to consider when evaluating the outcomes of coaching. Interestingly, two of the included RCTs evaluated the effectiveness of coaching for female participants only, and found significant benefits [44,45]. Qualitative research may be useful to explore the mechanisms of change among coaching participants and generate hypotheses regarding its relative effectiveness within and across groups of physicians.

Strengths and limitations
This review identifies five RCTs at relatively low risk of bias that show evidence supporting the effectiveness of coaching for physicians. There are some limitations based on inconsistent and incomplete reporting were common across the included studies. In addition, most studies were not RCTs, and these were all at moderate to serious risk of bias. Nevertheless, this review addresses an emerging and promising intervention for physician wellness at a time when levels of distress and burnout are on the rise. It also identifies key gaps for future research on coaching to address.

Implications for researchers, clinicians and policymakers
Based on the available evidence, coaching may be a promising intervention for improving physician wellness but requires further study to precisely determine its optimal delivery and effectiveness. Additional RCTs with standardized reporting and outcome measures, sub-group analyses, and qualitative exploratory work are needed. At the same time, coaching may be an appealing intervention to clinicians given its flexibility and strengths-based approach. Should future research conclusively support its effectiveness for improving physician wellness, healthcare organizations may wish to facilitate coaching as part of their wellness programs for physicians.

Conclusions
Evidence from available RCTs suggests coaching for physicians can improve well-being and reduce distress/burnout. Non-randomized interventional studies have similar findings but face many limitations. Consistent reporting and standardized outcome measures are needed.